A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech.

After having a few drinks at a local seafood restaurant, the client’s husband noticed his wife’s speech became difficult to understand.

The triage nurse does a rapid assessment of the client.

1915: Client arrives via personal car to emergency department with facial drooping and garbled speech.

Click to highlight the data that indicate the client is in need of immediate health interventions.

A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech.

After having a few drinks at a local seafood restaurant, the client’s husband noticed his wife’s speech became difficult to understand.

1915: Client arrives via personal car to emergency department with facial drooping and garbled speech.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A rationale:

The client’s presentation of a noticeable facial droop and garbled speech are classic symptoms of a stroke. These symptoms indicate that the brain is not receiving enough oxygen, which can lead to permanent damage if not treated immediately. Therefore, this client requires immediate health interventions.

Choice B rationale:

This choice is identical to Choice A. The client’s noticeable facial droop and garbled speech are indicative of a stroke and require immediate attention.

Choice C rationale:

This choice is also identical to Choices A and B. The client’s symptoms are indicative of a stroke, which is a medical emergency that requires immediate intervention.

Choice D rationale:

While the change in the client’s speech after having a few drinks at a restaurant could be due to alcohol consumption, it could also be a symptom of a stroke, especially when combined with the facial droop. However, this choice does not directly indicate the need for immediate health interventions as it lacks the specificity of the symptoms compared to Choices A, B, and C.

Choice E rationale:

The time of arrival and mode of transportation do not directly indicate the need for immediate health interventions. However, the mention of facial drooping and garbled speech upon arrival at the emergency department reinforces the urgency of the situation, as these are classic symptoms of a stroke. In conclusion, Choices A, B, C, and E all highlight data that indicate the client is in need of immediate health interventions due to potential stroke symptoms. It’s important to note that strokes require immediate medical attention to minimize brain damage and potential complications. Normal ranges for lab parameters would not apply in this scenario as it’s based on clinical observations rather than laboratory findings.

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Correct Answer is ["A","B","C","E","F"]

Explanation

Choice A rationale:

Hyperglycemia is a key symptom of DKA. It occurs when there is an insufficient amount of insulin in the body to allow glucose to enter cells for use as energy. As a result, the body begins to break down fat for fuel, leading to the production of ketones and causing blood glucose levels to rise1. Normal blood glucose levels are between 4.0 to 6.0 mmol/L when fasting and up to 7.8 mmol/L two hours after eating2.

Choice B rationale:

Ketonuria, or the presence of ketones in the urine, is another symptom of DKA. When the body breaks down fat for energy, ketones are produced. If too many ketones build up in the blood, they can spill over into the urine1.

Choice C rationale:

Metabolic acidosis occurs in DKA due to the accumulation of ketones in the blood. Ketones are acidic, and when they build up in the blood, they cause the blood to become more acidic, leading to metabolic acidosis1.

Choice D rationale:

Hypokalemia is not a symptom of DKA. In fact, patients with DKA often have high potassium levels in their blood at presentation because acidosis causes potassium to move from inside the cells into the bloodstream1. However, during treatment for DKA, when insulin is administered and acidosis is corrected, potassium moves back into the cells and can lead to low potassium levels or hypokalemia1.

Choice E rationale:

Dehydration is a common symptom of DKA. High blood glucose levels lead to increased urination as the body tries to get rid of the excess glucose. This can result in dehydration1.

Choice F rationale:

Kussmaul respirations are a type of hyperventilation that occurs in DKA as the body tries to get rid of excess acids (ketones) through the lungs by breathing rapidly and deeply1.

A. Suicidal ideation is a diagnosis in itself. B. Suicidal ideation is more common in older adults. C. Suicidal ideation always involves a detailed plan for self-harm. D. Suicidal ideation can be a symptom of various underlying mental health conditions. E. Suicidal ideation can be a symptom of various underlying mental health conditions.

Correct Answer is D

Explanation

Choice A rationale:

This statement is incorrect. Suicidal ideation is not a diagnosis in itself but rather a symptom or thought process associated with various mental health conditions.

Choice B rationale:

This statement is incorrect. Suicidal ideation can occur in individuals of all age groups, not just in older adults. It is not limited to any specific age demographic.

Choice C rationale:

This statement is incorrect. Suicidal ideation does not always involve a detailed plan for self-harm. It can range from fleeting thoughts of self-harm to more detailed plans, but the severity can vary widely.

Choice D rationale:

This statement is accurate. Suicidal ideation can be a symptom of various underlying mental health conditions, including depression, anxiety disorders, bipolar disorder, and others. It involves thoughts of self-harm or suicide, which may or may not be accompanied by specific plans.

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Naxlex Comprehensive Predictor Exams

Patient Data. Exhibits What are the signs and symptoms of DKA? Select all that apply.

Correct Answer is ["A","B","C","E","F"]

Explanation

A nurse is providing education to a group of healthcare professionals about suicide and suicidal ideation. Which of the following statements accurately describes suicidal ideation?

Correct Answer is D

Explanation

A client is admitted to the intensive care unit (ICU) with a spinal cord injury (SCI) following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?

When caring for an older male client with urinary frequency, which measure is most important for the nurse to implement to help the client prepare to go to bed for the night?

The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? (Select all that apply.).

While caring for a client with a full-thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

A nurse is teaching a group of older adults about the effects of aging on the neurological system. Which of the following statements should the nurse include as correct? (Select all that apply.).